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Biomedical subjects

M Juneau

Publications and source records attributed to M Juneau.

At least 37 records · Page 2Linked to original sources
PubMed1992

Reactivation of unstable angina after the discontinuation of heparin.

BACKGROUND: Heparin is an effective, widely used treatment for unstable angina. Among patients enrolled in a double-blind, randomized, placebo-controlled trial comparing intravenous heparin, aspirin, both treatments, and neither during the acute phase of unstable angina, we encountered patients in whom unstable angina was reactivated after heparin was discontinued. METHODS: The study population included 403 of the original 479 patients in the trial who had completed six days of blinded therapy without refractory angina or myocardial infarction. After the discontinuation of therapy, clinical events, including reactivation of unstable angina and myocardial infarction occurring within 96 hours after hospitalization, were closely monitored. RESULTS: Early reactivation occurred in 14 of the 107 patients who received heparin alone, as compared with only 5 patients in each of the other three study groups (P less than 0.01). These reactivations required urgent intervention (thrombolysis, angioplasty, or coronary-bypass surgery) in 11 patients treated with heparin alone, but in only 2 patients in the other groups combined (P less than 0.01). Four of the six patients who had a myocardial infarction during a reactivation of their disease were in the heparin group. Reactivations in this group occurred in a cluster a mean (+/- SD) of 9.5 +/- 5 hours after the discontinuation of the study drug but were randomly distributed over the initial 96 hours in the other three groups. CONCLUSIONS: Although heparin is beneficial in treating unstable angina, the disease process may be reactivated within hours of the discontinuation of this drug. Concomitant therapy with aspirin may prevent this withdrawal phenomenon.

Acute Disease↗
PubMed1992

Differential long-term impact of in-hospital symptoms of psychological stress after non-Q-wave and Q-wave acute myocardial infarction.

Because of their unstable pathophysiology, it was hypothesized that patients with non-Q-wave acute myocardial infarctions (AMI) would be more vulnerable to the negative effects of psychological stress than patients with Q-wave AMI, and thus would be more likely to benefit from programs aimed at relieving stress. This hypothesis was tested through secondary analysis of data from a 1-year randomized clinical trial of psychological stress monitoring and intervention after AMI. After discharge, treatment group patients were telephoned each month and asked to respond to an index of psychological stress symptoms (General Health Questionnaire GHQ-20). Those with high stress symptoms (GHQ greater than or equal to 5) received home nursing visits. Control group patients received usual care. The sample consisted of 461 men, aged 31 to 86 years, who responded to the GHQ-20 before hospital discharge. Patients were followed for 5 years using record data. There were 321 Q-wave AMIs, 112 non-Q-wave AMIs and 28 indeterminate electrocardiograms. Life-table analyses showed that among patients with non-Q-wave AMIs receiving usual care, high stress in the hospital (GHQ greater than or equal to 5) was associated with a 1-year relative risk (RR) of cardiac mortality of 5.49 +/- 1.39 (p = 0.01). In comparison, control patients with Q-wave MIs had no stress-related increase in risk (RR = 0.41 +/- 2.08, p = 0.40). In the treatment group, the patients with non-Q-wave AMIs did not experience an increase in risk associated with high stress (RR = 1.80 +/- 1.79, p = 0.52).(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1992

Effect of diltiazem slow-release formulation on silent myocardial ischemia in stable coronary artery disease. The Canadian Multicenter Diltiazem Study Group.

Silent myocardial ischemia is associated with adverse outcome in several subsets of coronary artery disease patients. This article presents results of a placebo-controlled, randomized, double-blind study of the effects of sustained-release diltiazem (180 mg twice daily) on ischemic episodes in 60 patients with documented coronary artery disease. The mean age of the study population was 60 years and 93% were male. The mean number of episodes of silent ischemia per patient was 5.6 (placebo) and 2.8 (diltiazem), a 50% reduction (p less than 0.0001). Duration of ST-segment depression was 119 minutes (placebo) and 67 minutes (diltiazem), a 44% reduction (p less than 0.001). This study demonstrates that sustained-release diltiazem can significantly reduce the frequency and total duration of silent ischemic episodes.

Adult↗
PubMed1992

Symptom-limited versus low level exercise testing before hospital discharge after myocardial infarction.

OBJECTIVE: This study was undertaken to compare a low level and a symptom-limited test performed before hospital discharge after an uncomplicated myocardial infarction. BACKGROUND: Exercise testing after myocardial infarction provides useful prognostic information. Usually either a low level test is performed before hospital discharge or a symptom-limited test is performed at 3 weeks. METHODS: The study group comprised 202 patients with an uncomplicated myocardial infarction; 58 patients had a non-Q wave infarction and 115 patients had received thrombolytic therapy. Both a low level and a symptom-limited exercise test were performed in 200 of the 202 study patients in randomized order on consecutive days, a mean of 7.4 +/- 2.3 days after infarction. RESULTS: The symptom-limited test required a considerably greater effort than the low level test: exercise duration was 554 +/- 209 versus 389 +/- 125 s (p less than 0.0001), and peak work load was 5.7 +/- 1.8 versus 4.2 +/- 1.1 METs (p less than 0.0001). The peak heart rate was higher during the symptom-limited test (121 +/- 20 vs. 108 +/- 14 beats/min, p less than 0.0001), as was the rate-pressure product. The number of patients who developed ST segment depression greater than or equal to 1 mm increased from 56 during the low level test to 89 during the symptom-limited test (p less than 0.0001). ST segment depression greater than or equal to 2 mm occurred in 22 patients during the low level test and in 41 patients during the symptom-limited test, an 86% increase (p less than 0.0001). The number of patients with either angina or ST depression greater than or equal to 1 mm increased from 66 to 105 (p less than 0.0001) with the symptom-limited test. Exercise test results were similar for patients with a Q wave or a non-Q wave infarction. Exercise duration was longer and exercise-induced ST depression less frequent in patients who had received thrombolytic therapy. CONCLUSIONS: A symptom-limited exercise test performed before hospital discharge after uncomplicated myocardial infarction provides a significantly greater cardiovascular stress than does a low level test and is associated with an ischemic response nearly twice as frequently. The prognostic significance of a positive response at higher work loads has not been defined.

Angina Pectoris↗
PubMed1991

Effect of diltiazem on symptomatic and asymptomatic episodes of ST segment depression occurring during daily life and during exercise.

BACKGROUND: Silent myocardial ischemia is an adverse prognostic marker in patients with coronary disease; however, controlled data on the effect of treatment are sparse and contradictory, and the relations among the occurrence of ST segment depression, drug efficacy, and heart rate are unclear. METHODS AND RESULTS: Sixty patients with stable coronary artery disease, a positive treadmill exercise test and asymptomatic ST segment depression on ambulatory electrocardiographic recording were assessed in a multicenter, double-blind, placebo-controlled, cross-over trial. Treadmill exercise tests and 72-hour electrocardiographic recordings were obtained at the end of two 2-week treatment periods with sustained-release diltiazem 180 mg b.i.d. or equivalent placebo. Episodes of asymptomatic ST depression decreased by 50% or more in 70% of the patients from a median number of 4.5 (range, 0-19) to 1.5 (range, 0-13) (p = 0.0001); their cumulative duration also decreased from 78.5 (range, 0-60) to 24.5 (range, 0-411) minutes (p = 0.001). No circadian variation was found in the efficacy of diltiazem. The occurrence of ischemic type ST segment depression was modulated by changes in heart rate rather than by absolute heart rate. Diltiazem also improved exercise test end points but to a lesser extent. Time to ST segment depression increased to 341 +/- 148 from 296 +/- 154 seconds (p = 0.005). Although less frequent with diltiazem administration (45 versus 54 patients, p less than 0.03), exercise-induced ST depression was more often asymptomatic (98% versus 72% of patients, p less than 0.0001). CONCLUSIONS: Diltiazem reduces the frequency and severity of ischemic type ST depression in patients with stable coronary artery disease.

Activities of Daily Living↗
PubMed1991

Role of diltiazem in the treatment of silent myocardial ischemia.

Silent myocardial ischemia is a frequent finding when Holter monitoring is done in patients with advanced coronary disease. Silent ischemia is associated with a worse prognosis in patients with stable or unstable angina, survivors of myocardial infarction, and populations at risk for coronary disease. Whether medical therapy for silent ischemia improves prognosis is not known. In a randomized, placebo-controlled, multicenter trial of 60 patients with documented coronary disease, positive exercise tests, and ischemic episodes on Holter monitoring, long-acting diltiazem reduced ischemic episodes by 50% compared to placebo, from a mean of 5.6 to 2.8 (p less than 0.0001). Efficacy was maintained over 24 h and diltiazem also significantly improved exercise test parameters. Three smaller studies also demonstrated that diltiazem effectively reduces ambulatory ischemia; however, results with nifedipine are conflicting, with several studies showing no benefit. In contrast, beta-blockers reliably reduce ischemic episodes. The role of medical therapy for silent ischemia will be clarified only when its effect upon morbidity and mortality are determined.

Adult↗
PubMed1989

Usefulness of sustained-release diltiazem for stable angina pectoris.

Sustained-release diltiazem, 120 and 180 mg twice daily, was assessed in a multicenter, double-blind, randomized, placebo-controlled trial in 65 stable angina patients with exercise-induced ST depression. Exercise testing was performed 12 +/- 1 hours after the last dose at the end of each of the 3 treatment weeks. Both dose levels of drug reduced spontaneous angina (p less than 0.001) and increased exercise duration (p less than 0.01) and time to 1-mm ST depression (p less than 0.001). No differences were noted between the 2 dose levels. Rate-pressure product at maximal exercise was similar for the 3 groups. Only 1 patient terminated the study because of adverse drug effects; severe adverse effects occurred in 1 placebo and 1 low-dose period. Sustained-release diltiazem is safe and efficacious monotherapy for patients with stable angina.

Adult↗
PubMed1989

Influence of fibrinolysis and percutaneous transluminal coronary angioplasty on the frequency of ventricular premature complexes.

This study evaluated the aggressive management of acute myocardial infarction to determine how it modifies the incidence of ventricular arrhythmias and of other determinants of prognosis during recovery. The population consisted of 344 consecutive survivors of acute myocardial infarction admitted to the hospital with chest pain and ST-segment elevation on the electrocardiogram. Three groups constituted the study population: 168 control patients treated conservatively or in whom fibrinolysis was unsuccessful, 73 patients successfully reperfused with intravenous streptokinase and 103 patients with both successful fibrinolysis and successful percutaneous transluminal coronary angioplasty (PTCA) of the artery responsible for the infarct. Early spontaneous angina occurred in 47 control patients (28%), 25 streptokinase patients, (34%) and, in significantly fewer number, 20 PTCA patients (19%, p less than 0.05). Similarly, exercise-induced ST-segment depression on the predischarge exercise treadmill test was less frequent with PTCA (p less than 0.05). The number of ventricular premature complexes (VPCs) on a 24-hour Holter recording was 40 +/- 123/hr in the control group and significantly less in the streptokinase (21 +/- 64, p less than 0.05) and PTCA groups (17 +/- 61, p less than 0.05). Three or more VPCs/hr were observed in 50% of the control patients, compared with 29% of the streptokinase and 27% of the PTCA patients (p less than 0.005). Mean radionuclide ejection fraction was greater than 40% and similar in the 3 study groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Angioplasty, Balloon↗
PubMed1989

Limited usefulness of intermittent nitroglycerin patches in stable angina.

The efficacy of continuous and intermittent nitroglycerin patches (10 mg/day) was compared in a randomized, placebo-controlled trial in 36 patients with stable angina and reproducible, exercise-induced ST depression. Intermittent treatment was administered either 18 or 14 h/day with an intermission of 6 h or 10 h, respectively. Exercise tests were performed during the last 2 h of patch application. Compared with placebo, neither continuous nitroglycerin nor the two intermittent regimens prolonged total treadmill time or time to 1 mm ST depression. No treatment eliminated exercise-induced ST depression in greater than 1 of the 36 patients. Time to angina was prolonged (by 40 +/- 66 s) only during the "10 h off" treatment (p = 0.001); time to angina increased by greater than or equal to 20% in 13 patients. Responders to treatment could be predicted by a short history of angina (p less than 0.05) and a time to angina less than or equal to 250 s during the placebo test. For each treatment, greater than or equal to 25 of the patients reported headache; 4 additional patients dropped out because of severe headache and 2 others because of a coronary event in a washout period. Thus, in most patients with stable angina, side effects outweight any benefit demonstrable with this therapy.

Administration, Cutaneous↗
PubMed1989

Exercise-induced myocardial ischemia in a cold environment. Effect of antianginal medications.

The influence of cold on the threshold for myocardial ischemia and the efficacy of antianginal drugs in a cold environment were assessed in 24 patients with stable angina and exercise-induced ST depression. Treadmill exercise tests were done according to a randomized double-blind protocol 90 minutes after administration of placebo, 80 mg propranolol, or 120 mg diltiazem, each at both -8 degrees and 20 degrees C. Eight of the patients were classified by history as cold-sensitive before the study. For the entire group, none of the exercise end points differed significantly between cold and normal temperatures with placebo. However, cold-sensitive patients developed 1 mm ST depression 30% sooner (169 +/- 41 versus 244 +/- 38 seconds, p less than 0.01) at -8 degrees C compared with 20 degrees C. At the onset of ischemia, rate-pressure product was lower in the cold (19.8 +/- 1.0 versus 22.0 +/- 1.6 x 10(-3), p less than 0.05). Both propranolol and diltiazem prolonged time to onset of 1 mm ST depression at both temperatures. The magnitude of improvement at -8 degrees C was equal to that at 20 degrees C, and differences between the two drugs were not statistically significant. Only diltiazem prolonged total exercise duration. Thus, as assessed by exercise testing, cold does not worsen ischemic threshold in most stable angina patients. However, in a subgroup identifiable by history, ischemic threshold is lower in the cold. Propranolol and diltiazem are as effective for exercise-induced ischemia in a cold environment as at normal temperatures.

Angina Pectoris↗
PubMed1988

Aspirin, heparin, or both to treat acute unstable angina.

We tested the usefulness of aspirin (325 mg twice daily), heparin (1000 units per hour by intravenous infusion), and a combination of the two in the early management of acute unstable angina pectoris in a double-blind, randomized, placebo-controlled trial involving 479 patients. The patients entered the study as soon as possible after hospital admission (at a mean [+/- SD] of 7.9 +/- 8.0 hours after the last episode of pain), and the study was ended after 6 +/- 3 days, when definitive therapy had been selected. Major end points--refractory angina, myocardial infarction, and death--occurred in 23, 12, and 1.7 percent of the 118 patients receiving placebo, respectively. Heparin was associated with a decrease in the occurrence of refractory angina (P = 0.002). The incidence of myocardial infarction was significantly reduced in the groups receiving aspirin (3 percent; P = 0.01), heparin (0.8 percent; P less than 0.001), and aspirin plus heparin (1.6 percent, P = 0.003), and no deaths occurred in these groups. There were too few deaths overall to permit evaluation of the effect of treatment on this end point. The combination of aspirin and heparin had no greater protective effect than heparin alone but was associated with slightly more serious bleeding (3.3 vs. 1.7 percent). We conclude that in the acute phase of unstable angina, either aspirin or heparin treatment is associated with a reduced incidence of myocardial infarction, and there is a trend favoring heparin over aspirin. Heparin treatment is also associated with a reduced incidence of refractory angina.

Acute Disease↗
PubMed1988

Early return to work after uncomplicated myocardial infarction. Results of a randomized trial.

To determine if an occupational work evaluation could shorten the time to return to work, 201 employed men aged 49 +/- 7 years who were recovering from uncomplicated myocardial infarction were randomized to usual care (n = 102) or to an occupational work evaluation (n = 99). The occupational work evaluation consisted of a symptom-limited treadmill test performed 23 +/- 3 days after myocardial infarction and a formal recommendation to the patient and primary physician that the patient return to work within the next two weeks. The groups did not differ in age, medical status, comorbid disease, occupation type, or years on the job. At six months, 92% of patients receiving the intervention and 88% of patients receiving usual care were working either full- or part-time. Return to full-time work occurred at a median of 51 days in patients receiving the intervention and 75 days in patients receiving usual care. This 32% reduction in the convalescence period was associated with +2102 of additional earned salary per intervention patient in the six months after myocardial infarction. One or more recurrent cardiac events occurred in 14 intervention patients (one death, one nonfatal myocardial infarction, three angioplasties, and nine coronary surgeries) and in 13 usual-care patients (two deaths, three nonfatal myocardial infarctions, six angioplasties, and seven coronary surgeries) in the six months after myocardial infarction. The early return to work of low-risk patients based on an occupational work evaluation is associated with important economic benefits.

Attitude to Health↗
PubMed1988

[Benefits of exertion in normal subjects and patients with coronary disease].

For over thirty years, many epidemiological studies have demonstrated that physical exercise, practiced regularly, makes it possible to reduce the risk of coronary heart disease significantly. Exercise helps to modify most risk factors: improvement in the levels of serum lipids, a decrease in resting blood pressure and submaximal effort, improvement in carbohydrate metabolism, discontinuation of smoking, decreased platelet aggregation, decreased circulating catecholamines, etc. Other scientific findings tend to demonstrate that exercise may also reduce the incidence of post-infarction coronary accidents (secondary prevention). The amount of exercise necessary to obtain these beneficial effects consists of 3 to 4 training sessions per week, 30 to 40 minutes for each. The intensity of exercise the patient undergoes during each session should vary between 65 and 90% of his maximum heart rate.

Adult↗
PubMed1987

Effectiveness of self-monitored, home-based, moderate-intensity exercise training in middle-aged men and women.

The effects of 6 months of self-monitored, home-based exercise training on maximal oxygen uptake (VO2 max), body composition and plasma lipid levels of healthy, sedentary, middle-aged persons were evaluated in 60 men, aged 49 +/- 6 years, and 60 women, aged 47 +/- 5 years. Moderate-intensity training was performed 5 times per week in sessions of 47 +/- 7 minutes and 54 +/- 8 minutes for men and women, respectively. The individually prescribed range of heart rate corresponded to 65 to 77% of the peak value during symptom-limited treadmill testing (mean of 72% for men and 69% for women). Caloric expenditure per training session was approximately 345 kcal for men and 235 kcal for women. VO2 max increased 15% in men and 9% in women (both p less than 0.01). The greater increase in VO2 max in men than in women primarily reflected greater adherence to training in men (greater than or equal to 90% vs greater than or equal to 75%). The increase in VO2 max in women who showed very high adherence was comparable to that of men. Body weight decreased, by 1.5 +/- 10 kg, in men (p less than 0.05) but not in women undergoing training. No significant training-induced changes in plasma lipid levels were noted in either men or women. Baseline orientation and follow-up telephone calls required less than 1 hour of staff time per participant. Self-monitored, moderate-intensity, home-based exercise training significantly increases functional capacity in healthy, middle-aged men and women. Such training provides an alternative to group-based exercise training.

Adult↗
PubMed1987

Assessment by a microprocessor of adherence to home-based moderate-intensity exercise training in healthy, sedentary middle-aged men and women.

Research in exercise training of healthy persons, which has been conducted almost exclusively in supervised group programs, is relatively expensive for the investigator and inconvenient for the participant. To overcome these obstacles, self-monitored moderate-intensity home-based exercise training was prescribed for 28 middle-aged men and 26 middle-aged women. The median energy expenditure prescribed for each of 5 weekly exercise sessions was 4 cal/kg body weight, or 317 kcal for men and 265 kcal for women, corresponding to a median duration of 45 and 60 minutes, respectively. In the next 24 weeks, peak oxygen uptake increased 13.7% in men who exercised, from 31 +/- 4 to 37 +/- 4 ml/kg/min, and 10% in women who exercised, from 26 +/- 4 to 29 +/- 5 ml/kg/min (p less than 0.001 for both comparisons). The proportion of prescribed caloric expenditure per session, which was documented by a solid-state heart rate recorder, was 108% in men and 90% in women. The duration of training at heart rates above the prescribed range approximated 10 minutes per session for both men and women; the proportion of total caloric expenditure represented by exercise at heart rates exceeding the prescribed limit was 9% for men and 4% for women. The proportion of time spent within the prescribed heart rate range during training sessions was 76% for men and 84% for women. Training-induced musculoskeletal problems were reported by 6 men and no women. No subject sought medical attention and all resumed training within 1 week.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗